Medicare Benefits Schedule - Note TN.1.4

Medicare benefits are not payable in respect of ANY other item in the Medicare Benefits Schedule, including Diagnostic Imaging and Pathology (with the exception of items 73384, 73385, 73386 and 73387) in lieu of or in connection with items 13200 - 13221.  Specifically, Medicare benefits are not payable for these items in association with items 104, 105, 14203, 14206, 35631, 35632, 35637, 35641, pathology tests (not including pathology items 73384, 73385, 73386 and 73387) or diagnostic imaging. 

A treatment cycle that is a series of treatments for the purposes of ART services is defined as beginning either on the day on which treatment by superovulatory drugs is commenced or on the first day of the patient's menstrual cycle, and ending either; not more than 30 days later, or if a service mentioned in item 13212, 13215 or 13221 is provided in connection with the series of treatments-on the day after the day on which the last of those services is provided. 

The date of service in respect of treatment covered by Items 13200, 13201, 13203, 13209 and 13218 is DEEMED to be the FIRST DAY of the treatment cycle. 

Items 13200, 13201, 13202 and 13203 are linked to the supply of hormones under the Section 100 (National Health Act) arrangements. Providers must notify Services Australia of Medicare card numbers of patients using hormones under this program, and hormones are only supplied for patients claiming one of these four items. 

Medicare benefits are not payable for assisted reproductive services rendered in conjunction with surrogacy arrangements where surrogacy is defined as 'an arrangement whereby a woman agrees to become pregnant and to bear a child for another person or persons to whom she will transfer guardianship and custodial rights at or shortly after birth'. 

NOTE: Items 14203 and 14206 are not payable for artificial insemination.

Related Items: 104 105 13200 13201 13202 13203 13209 13212 13215 13218 13221 14203 14206 35631 35632 35637 35641 66695 66698 66701 66704 66707 73384 73385 73386 73387 73521 73525

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Professional attendance at consulting rooms or hospital by a specialist in the practice of the specialist's specialty after referral of the patient to the specialist-each attendance, other than a second or subsequent attendance, in a single course of treatment, other than a service to which item 106, 109 or 16401 applies

Fee: $95.60 Benefit: 75% = $71.70 85% = $81.30

(See para AN.0.7, AN.0.25, AN.0.76, AN.2.1, AN.40.1, TN.1.4 of explanatory notes to this Category)

Professional attendance by a specialist in the practice of the specialist's specialty following referral of the patient to the specialist-an attendance after the first in a single course of treatment, if that attendance is at consulting rooms or hospital, other than a service to which item 16404 applies

Fee: $48.05 Benefit: 75% = $36.05 85% = $40.85

(See para AN.0.7, AN.0.25, AN.0.70, AN.2.1, AN.3.1, AN.40.1, TN.1.4 of explanatory notes to this Category)

Semen examination for presence of spermatozoa or examination of cervical mucus for spermatozoa (Huhner's test)

Fee: $9.70 Benefit: 75% = $7.30 85% = $8.25

(See para TN.1.4 of explanatory notes to this Category)

Sperm antibodies - sperm-penetrating ability - 1 or more tests

Fee: $28.35 Benefit: 75% = $21.30 85% = $24.10

(See para TN.1.4 of explanatory notes to this Category)

Multiple Operation Rule

Operative laparoscopy, including any of the following:
(a) unilateral or bilateral ovarian cystectomy;
(b) salpingo-oophorectomy;
(c) salpingectomy for tubal pathology (including ectopic pregnancy by tubal removal or salpingostomy, but excluding sterilisation);
(d) excision of mild endometriosis;
not being a service associated with a service to which any other intraperitoneal or retroperitoneal procedure item (other than item 30724 or 30725) applies (H)

(Anaes.) (Assist.)

Fee: $783.20 Benefit: 75% = $587.40

(See para TN.1.4, TN.8.2, TN.8.229, TN.8.248 of explanatory notes to this Category)

Multiple Operation Rule

Complicated operative laparoscopy, including either or both of the following:
(a) excision of moderate endometriosis;
(b) laparoscopic myomectomy for a myoma of at least 4cm, including incision and repair of the uterus;
not being a service associated with a service to which any other intraperitoneal or retroperitoneal procedure item (other than item 30724 or 30725 or 35658) applies (H)

(Anaes.) (Assist.)

Fee: $978.90 Benefit: 75% = $734.20

(See para TN.1.4, TN.8.2, TN.8.229, TN.8.248 of explanatory notes to this Category)

Multiple Operation Rule

Operative laparoscopy, including any of the following:
(a) excision or ablation of minimal endometriosis;
(b) division of pathological adhesions;
(c) sterilisation by application of clips, division, destruction or removal of tubes;
not being a service associated with another laparoscopic procedure (H) 

NOTE: Strict legal requirements apply in relation to sterilisation procedures on minors. Medicare benefits are not payable for services not rendered in accordance with relevant Commonwealth and State and Territory law. Observe the explanatory note before submitting a claim.

(Anaes.) (Assist.)

Fee: $447.55 Benefit: 75% = $335.70

(See para TN.1.4, TN.8.46, TN.8.229, TN.8.248 of explanatory notes to this Category)

Multiple Operation Rule

Severe endometriosis, laparoscopic resection of, involving 2 of the following procedures:
(a) resection of the pelvic side wall including dissection of endometriosis or scar tissue from the ureter;
(b) resection of the Pouch of Douglas;
(c) resection of an ovarian endometrioma greater than 2 cm in diameter;
(d) dissection of bowel from uterus from the level of the endocervical junction or above (H)

(Anaes.) (Assist.)

Fee: $1,367.85 Benefit: 75% = $1,025.90

(See para TN.1.4, TN.8.229, TN.8.248 of explanatory notes to this Category)

Genetic analysis, for a patient who is eligible for this service under clause 2.7.3A of the pathology services table (see PR.7.1), of samples from the patient and (if relevant) the patient’s reproductive partner, for the purpose of providing an assay for pre‑implantation genetic testing, requested by a specialist or consultant physician

Applicable not more than once per patient episode per disorder (of a kind described in clause 2.7.3A (PR.7.1)) per reproductive relationship

Fee: $1,736.00 Benefit: 75% = $1,302.00 85% = $1,637.30

(See para PR.7.1, TN.1.4 of explanatory notes to this Category)

Genetic analysis, for a patient who is eligible for this service under clause 2.7.3A of the Pathology Services Table (see PR.7.1), of embryonic tissue from a sample from one embryo, if:

(a) the analysis is:

(i) requested by a specialist or consultant physician; and

(ii) for the purpose of providing a pre‑implantation genetic test; and

(iii) performed on an embryo that was produced in a single assisted reproductive treatment cycle; and

(b) the service is not a service to which item 73386 or 73387 applies for the same assisted reproductive treatment cycle

Applicable not more than once per embryo

Fee: $635.00 Benefit: 75% = $476.25 85% = $539.75

(See para PR.7.1, TN.1.4 of explanatory notes to this Category)

Genetic analysis, for a patient who is eligible for this service under clause 2.7.3A of the Pathology Services Table (see PR.7.1), of embryonic tissue from samples from 2 embryos, if:

(a) the analysis is:

(i) requested by a specialist or consultant physician; and

(ii) for the purpose of providing a pre‑implantation genetic test; and

(iii) performed on embryos that were produced in a single assisted reproductive treatment cycle; and

(b) the service is not a service to which item 73385 or 73387 applies for the same assisted reproductive treatment cycle

Applicable not more than once per assisted reproductive treatment cycle for the 2 embryos tested

Fee: $1,270.00 Benefit: 75% = $952.50 85% = $1,171.30

(See para PR.7.1, TN.1.4 of explanatory notes to this Category)

Genetic analysis, for a patient who is eligible for this service under clause 2.7.3A of the Pathology Services Table (see PR.7.1), of embryonic tissue from samples from 3 or more embryos, if:

(a) the analysis is:

(i) requested by a specialist or consultant physician; and

(ii) for the purpose of providing a pre‑implantation genetic test; and

(iii) performed on embryos that were produced in a single assisted reproductive treatment cycle; and

(b) the service is not a service to which item 73385 or 73386 applies for the same assisted reproductive treatment cycle

Applicable not more than once per assisted reproductive treatment cycle for the 3 or more embryos tested

Fee: $1,905.00 Benefit: 75% = $1,428.75 85% = $1,806.30

(See para PR.7.1, TN.1.4 of explanatory notes to this Category)

HORMONE OR LIVING TISSUE IMPLANTATION, by direct implantation involving incision and suture

(Anaes.)

Fee: $56.30 Benefit: 75% = $42.25 85% = $47.90

(See para TN.1.4, TN.1.17 of explanatory notes to this Category)

HORMONE OR LIVING TISSUE IMPLANTATION  by cannula

Fee: $39.20 Benefit: 75% = $29.40 85% = $33.35

(See para TN.1.4, TN.1.17 of explanatory notes to this Category)

Assisted reproductive technologies superovulated treatment cycle proceeding to oocyte retrieval, involving the use of drugs to induce superovulation and including quantitative estimation of hormones, ultrasound examinations, all treatment counselling and embryology laboratory services but excluding artificial insemination, transfer of frozen embryos or donated embryos or ova or a service to which item 13201, 13202, 13203 or 13218 applies, being services rendered during one treatment cycle—initial cycle in a single calendar year

Fee: $3,424.00 Benefit: 75% = $2,568.00 85% = $3,325.30

(See para TN.1.4 of explanatory notes to this Category)

Assisted reproductive technologies superovulated treatment cycle proceeding to oocyte retrieval, involving the use of drugs to induce superovulation and including quantitative estimation of hormones, ultrasound examinations, all treatment counselling and embryology laboratory services but excluding artificial insemination, transfer of frozen embryos or donated embryos or ova or a service to which item 13200, 13202, 13203 or 13218 applies, being services rendered during one treatment cycle—each cycle after the first in a single calendar year

Fee: $3,202.80 Benefit: 75% = $2,402.10 85% = $3,104.10

(See para TN.1.4 of explanatory notes to this Category)

Assisted reproductive technologies superovulated treatment cycle that is cancelled before oocyte retrieval, involving the use of drugs to induce superovulation and including quantitative estimation of hormones and ultrasound examinations, but excluding artificial insemination, transfer of frozen embryos or donated embryos or ova or a service to which item 13200, 13201, 13203 or 13218 applies, being services rendered during one treatment cycle

Fee: $512.40 Benefit: 75% = $384.30 85% = $435.55

(See para TN.1.4 of explanatory notes to this Category)

Ovulation monitoring services for artificial insemination or gonadotrophin, stimulated ovulation induction, including quantitative estimation of hormones and ultrasound examinations, being services rendered during one treatment cycle but excluding a service to which item 13200, 13201, 13202, 13212, 13215 or 13218 applies

Fee: $535.70 Benefit: 75% = $401.80 85% = $455.35

(See para TN.1.4 of explanatory notes to this Category)

Planning and management of a referred patient by a specialist for the purpose of treatment by assisted reproductive technologies or for artificial insemination—applicable once during a treatment cycle

Fee: $93.20 Benefit: 75% = $69.90 85% = $79.25

(See para TN.1.4 of explanatory notes to this Category)

Oocyte retrieval for the purpose of assisted reproductive technologies—only if rendered in connection with a service to which item 13200 or 13201 applies

(Anaes.)

Fee: $390.15 Benefit: 75% = $292.65 85% = $331.65

(See para TN.1.4 of explanatory notes to this Category)

Transfer of embryos or both ova and sperm to the uterus or fallopian tubes, excluding artificial insemination—only if rendered in connection with a service to which item 13200, 13201 or 13218 applies, being services rendered in one treatment cycle

(Anaes.)

Fee: $122.35 Benefit: 75% = $91.80 85% = $104.00

(See para TN.1.4 of explanatory notes to this Category)

Preparation of frozen or donated embryos or donated oocytes for transfer to the uterus or fallopian tubes, by any means and including quantitative estimation of hormones and all treatment counselling but excluding artificial insemination services rendered in one treatment cycle and excluding a service to which item 13200, 13201, 13202, 13203 or 13212 applies

(Anaes.)

Fee: $873.45 Benefit: 75% = $655.10 85% = $774.75

(See para TN.1.4, TN.1.5 of explanatory notes to this Category)

Preparation of semen for the purpose of artificial insemination—only if rendered in connection with a service to which item 13203 applies

Fee: $55.90 Benefit: 75% = $41.95 85% = $47.55

(See para TN.1.4 of explanatory notes to this Category)

Quantitation in blood or urine of hormones and hormone binding proteins - ACTH, aldosterone, androstenedione, C-peptide, calcitonin, cortisol, DHEAS, 11-deoxycortisol, dihydrotestosterone, FSH, gastrin, glucagon, growth hormone, hydroxyprogesterone, insulin, LH, oestradiol, oestrone, progesterone, prolactin, PTH, renin, sex hormone binding globulin, somatomedin C(IGF-1), free or total testosterone, urine steroid fraction or fractions, vasoactive intestinal peptide,  - 1 test

(Item is subject to rule 6)

Fee: $30.50 Benefit: 75% = $22.90 85% = $25.95

(See para TN.1.4 of explanatory notes to this Category)

2 tests described in item 66695

(Item is subject to rule 6)

Fee: $43.70 Benefit: 75% = $32.80 85% = $37.15

(See para TN.1.4 of explanatory notes to this Category)

3 tests described in item 66695

(Item is subject to rule 6)

Fee: $56.90 Benefit: 75% = $42.70 85% = $48.40

(See para TN.1.4 of explanatory notes to this Category)

4 tests described in item 66695

(This fee applies where 1 laboratory, or more than 1 laboratory belonging to the same APA, performs the only 4 tests specified on the request form or performs 4 tests and refers the rest to the laboratory of a separate APA)

(Item is subject to rule 6)

Fee: $70.15 Benefit: 75% = $52.65 85% = $59.65

(See para TN.1.4 of explanatory notes to this Category)

5 or more tests described in item 66695

(Item is subject to rule 6)

Fee: $83.35 Benefit: 75% = $62.55 85% = $70.85

(See para TN.1.4 of explanatory notes to this Category)